All You Wanted to Know About
Medications But Were Afraid to
Ask
Medications and Potential Side
Effects Relevant to the Classroom
Nancy Rappaport, MD
Harvard Medical School
Presentation Goals
• To review processes of diagnosis and
formulation about kids that may need
medication
• Relevant information about medications
Symptoms of ADHD
• Inattentiveness
• Distractibility
• Impulsivity
*Often hyperactivity is considered
inappropriate for developmental age
children; however, ADHD manifests itself
in different ways.
ADHD: Core Symptom Areas
• Inattention
• Impulsivity/Hyperactivity
ADHD: Core Symptom Areas
• Negative impact on multiple areas of
functioning
• Social and academic deficits
• Patterns of comorbid disorders
The Human Brain
ADHD
• Genetic Origins
–
–
–
–
–
–
CNS insults
Fetal alcohol syndrome
Drug exposure
Serious head injury
Infection
Prematurity
• Environmental
Factors
– E.g., Lead poisoning
• Twin Studies
• ADHD Studies
Is there a simple test to
diagnose ADHD?
No “Gold Standard”
• “How come my son can be so focused when
he is playing video games or building a
model?”
• Observation captures variability
• Inefficient performance not an incapacity
(lazy)
• “When children or adults are distracted they
are paying attention to something else.
Whether it is soap falling into the bathtub,
an apple falling from a tree, or the peculiar
way an insect walks across the floor, small
attractions may lead to bigger ideas. Being
distracted, in other words, means otherwise
attracted.”
Ellen J. Langer, The Power of Mindful Learning
How many children and
adolescents have ADHD?
• Depends who you ask.
• Anywhere from 2-12% of children and
adolescents, 4.7% of adults, endorsed
childhood and current symptoms of ADHD
• On average, at least one child in every
classroom
Is ADHD a “guy thing?”
Problems Communicating
• Language impairment in a substantial
proportion of community and clinical
studies of school-age children with ADHD
(20-60% in a clinical study)
• Expressive language impaired - word
retrieval problems using nonspecific words
• Pragmatics - difficulties in the appropriate
timing (too much talk with transitions and
play settings)
• Decreased ability to express when planning
or organization (story-telling, group
directions)
• ADHD and reading disorder (15-30% of
ADHD students
• More likely with inattention and naming
difficulty
Game Plan of Evaluation
• Core symptoms
– Chronicity
– Pervasiveness
– Impairment and differential diagnosis
QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
• Treatment
• Psychoeducation
–What ADHD is and is not
–“A challenge, not an excuse.”
*School interventions
*Medications
NIMH MTA Study
• Medication treatment alone
• Medication management and behavioral
treatment
• Children did better with ADHD symptoms
as long as the medication was taken
Stimulant Treatment of ADHD
• Ritalin
• Dextroamphetamine
• Amphetamine mixed salts
What Medications Will Improve
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•
•
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•
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Academic performance
Short-term memory
Reaction time
Cognitive impulsivity
On-task behavior
Hyperactivity
What Medications Won’t Improve
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•
•
•
Mood
Anxiety
Temper
Specific learning disorder (no data on
speed, accuracy, or reading comprehension)
Management of Common
Stimulant-Induced Adverse
Effects
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•
•
•
•
Anorexia, nausea, weight loss
Insomnia, nightmares
Rebound phenomena
Irritability
Dysphoria, moodiness, agitation
Other Medications
• Strattera (stomache ache)
• Wellbutrin (antidepressant) - takes up to
four weeks to get a response
• Clonidine - reduces motor activity and
impulsiveness (sedation side effect)
Mood Disorders
Case Histories
Disturbing Statistics
Fig 1: Developmental and temporal trends in rates of
adolescent suicide. Data from Maguire & Pastore (1999).
15
10
10 -1 4 ye ars old
5
15 -1 9 ye ars old
19
96
19
94
19
92
19
90
19
88
19
86
0
19
80
a d o le sc en t s
R a t e p er 1 00 ,0 00
Fig. 1
Statistics (ctd.)
Fig 1.2: Developmental trends since 1950 in suicide rates for
15-19 yr old adolescents, by gender. Maguire & Pastore (1999).
20
15
Male ( 15-19 yrs)
10
5
Female ( 15-19
0
19
96
19
94
19
92
19
90
19
70
yr s)
19
50
ad o lescen t s
R at e p er 100,000
Fig. 1.2
• For young people 15-24 yrs old, suicide is
the third leading cause of death, behind
accidental injury and homicide – 2,000
adolescents 15-19 commit suicide each year
• Persons under age 25 accounted for 15% of
all suicides in 1997
• Within schools this statistic translates to (in
a district of 8,000 students) one suicide a
year
• Firearms are the most common method for
completed suicides, followed by ingestions
leading to overdose, and hanging
• 65% of completed suicides use handguns. The
increase in the rates of youth suicide (and the
number of deaths by suicide) over the past four
decades is largely related to the use of firearms as
a method of destruction
• Substance abuse/dependence is the probable
reason that adolescence attempts are more lethal
• There are 400 suicide attempts by teenage
boys for every completed suicide in males
• Four thousand suicide attempts per every
death in females
• Who uses the most effective method – Girls
or Boys?
• The Center for Disease Control (CDC) has
tracked by school survey since 1991 every
two years 12,000 to 16,000 students.
• Approximately 20% of students have had
suicidal ideation; 10% have made a suicide
attempt in a 12-month period; 1-3% of
teenagers will receive medical attention for
an attempt
• .01% will be successful
• Ideation is almost always episodic
Profile of Children with Completed
Suicides
• Immature problem solving that translates into
more impulsive behavior
• Less able to tolerate frustration (adult data shows
decreased serotonin)
• Unable to plan future actions
• Aggressive or violent outbursts
• Difficulty making decisions
• Less able to assess situations realistically than
non-suicidal children
• Loss of parent before the
age of 12
• History of parental abuse
• Early onset of suicidal
behavior (prepubertal)
predicts suicidal behavior in
adolescents
• Although suicides are rare in
children age 12 and under, suicide
attempts are NOT rare in bipolar
children age 12 and under (20%)
• Usually these children are difficult to treat
and there is considerable controversy about
the criteria as they are referred to as “rapid
cyclers and often have mood lability, mood
swings, affective storms, irritability and
aggressiveness, periodic agitation,
explosiveness and severe temper tantrums
which can also be in response to trauma and
family discord,” (Papolos 1999).
Psychological Autopsies
• Shaffer studied large numbers of completed
suicides at an average age of 16 (170
psychological suicide autopsies) in an
ethnically diverse population in 1984-86
interviewing multiple informants with
community control subjects.
• More than 90% of subjects who
committed suicide met criteria for at
least one major psychiatric diagnosis
• Half of these subjects had psychiatric
disorder for at least two years
• Link between psychopathology and
suicide
Organized plan, intent,
preparation
• One in four adolescents that completed
suicides show evidence of planning
• According to Shaffer the time-honored
clinical inquiry about planning is a poor
measure of serious intent
Important Implications
• Need for thorough diagnostic interview
• Never discount a threat especially in the
context of affective or substance abuse
disorders
• Importance of aggressive intervention in
first-episode affective illness
• The most common diagnostic groups were
mood disorders (52% major depression),
disruptive disorders and substance abuse
• A child with a mood disorder is four to five
times more likely to attempt suicide than a
child without a mood disorder
Completer Profile
• Evenly distributed by the SES, evenly
distributed by educated vs. uneducated,
Western states highest, 60% of firearms
• 50% of completers were never in therapy
• 75% of completers communicated thoughts
about their suicide aloud to several people
months before dying (“natural screeners”)
Strategies for Suicide Prevention
• Suicide awareness programs
• Screening
• First step of recognition
#1 FIND &
TREAT
ACTIVE DISORDER
e.g., Mood disorder,
substance abuse, anxiety
STRESS EVENT
e.g., In trouble with
law/school; loss;
humiliation
ACUTE MOOD
CHANGE
e.g., Anxiety-dread,
hopelessness, anger
1 INHIBITION
SOCIAL
i.e.
MENTAL STATE
Slowed down
SURVIVAL
Adapted from Shaffer & Greenberg, 2002
SUICIDAL
IDEATION
2
FACILITATION
UNDERLYING
TRAIT
Impulsive, intense,
serotonin abnormality
Strong
taboo;
vailable
support;
presence of
others;
difficult to
access
method
#2 STRESS
AVOIDANCE/
TOLERANCE
#3 CRISIS
SERVICES
#4 MEDIA
GUIDELINES &
POSTVENTION
SOCIAL
Recent example, weak
taboo, isolation
MENTAL STATE
#5 METHOD
CONTROL
Agitation
Method Availability/
Familiarity
SUICIDE
Types of Depression
• Major Depression Usually begins in the late
teens, but has been diagnosed in children as young as four
• Dysthymia Chronic, mild depression. Starts in
childhood and can last decades
• Bipolar disorder Older teens cycle between
mania and depression. Younger teens can experience both
symptoms at once
• Clinical vignettes
SIGECAPS
Sleep - too little or too much
lose Interest or pleasure
feelings of Guilt or worthlessness
decreased Energy
decreased Concentration
change in Appetite
Psychomotor agitation or retardation
Suicidal ideation
“I don’t care.”
“Depression is the mother of
anger”
• Irritability
• Duration of
symptoms
• Vague,
nonspecific
physical
complaints
• Rate of depression varies; with age, the rate
of the disorder increases
• .3% preschoolers
• 1-2% of elementary age boys and girls, 1:1
ratio
• 5% of adolescents with a 2:1 ratio of girls to
boys
Risk Factors
• Unresolved grief
• Childhood trauma
• Learned feelings of helplessness (negative
& hopeless)
• Anxiety disorder
Reprinted with permission
Stress and Protection in Different
Family Contexts
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High levels of conflict
“Child is expendable”
Inordinate shame or guilt
Noble self-sacrifice
Deflection away from other conflicts
“Stress clusters”
Impulsivity and aggression
Stress Protection (ctd.)
• Ask the family and the patient about how they
communicate and see if the patient can identify
who she/he relies on when stressed
• Assess the family’s capacity to monitor and
maintain sufficient watch over the adolescent
• Winnicott: “Why not tell him that you know
that when he steals he is not wanting the things
that he steals but he is looking for something
that he has a right to; that he is making a claim
on his mother and father because he feels
deprived of their love.”
Dysthymia
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•
•
•
•
Less severe form of depression
Long-term irritablemood
Low in energy
Not interested in activities
Often precursor of severe depression
• Adults often cycle whereas children tend to
have longstanding depression with only
infrequent, spontaneous remissions.
• Difficult to tell if a child is going through a
phase or suffering from clinical depression
• Spirito’s study drop out ranged from 35%40% for adolescents in treatment after
suicide attempts with three visits, 58% to
78% dropped out within nine visits
• Be careful of pathologizing kids that they
are “resistant” – timing is key and
sometimes therapy is used as a form of
castigation or shaming by families
Treatment
• Psychotherapy
• Cognitive Behavioral Therapy (CBT)
– Focuses on irrational beliefs or distorted
thoughts
– Learn to identify, test, and correct specific
distortions in their thinking
– Recognize the relationship between thinking,
feelings, and behaviors
Medications
• SSRI more effective than
placebo
Serotonin
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Distributed widely in the body
Discharged by neurons in the brain
Regulation of mood
Regulation of sleep
Medications
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SSRI
Prozac
Zoloft
Celexa
Luvox (anxiety)
Effexor
Wellbutrin
Serzone & Trazadone
“How long should a doctor treat
depression with medication?”
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Key: recognize side effects
Activation
Bipolar switching
celebration
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Dimensional issues or comorbid presence
Evolving psychopathology
Frontal lobe type symptoms (apathy)
Gastrointestinal symptoms
Sex
Bipolar Disorder
• Also known as manic depression, a mental
illness that causes a person’s moods to
swing from extremely happy and energized
(mania) to extremely sad (depression)
• Chronic illness; can be life-threatening
• Most often diagnosed in adolescence
Nirvana’s Lithium
I'm so happy 'cause today I've found my friends
They're in my head I'm so ugly, but that's okay, 'cause so are you...
We've broken our mirrors
Sunday morning is everyday for all I care...
And I'm not scared
Light my candles in a daze...
'Cause I've found god - yeah, yeah, yeah
I'm so lonely but that's okay I shaved my head...
And I'm not sad
And just maybe I'm to blame for all I've heard...
But I'm not sure I'm so excited, I can't wait to meet you there...
But I don't care I'm so horny but that's okay...
My will is good - yeah, yeah, yeah I like it - I'm not gonna crack
I miss you
I'm not gonna crack
I love you
I'm not gonna crack
I kill you
I'm not gonna crack
Bipolar Disorder (ctd.)
• Significant functional impairment
• Bipolar I people go through cycles of major
depression and mania
• Bipolar II similar to Bipolar I except that
people have hypomanic episodes, a milder
form of mania
• Rapid cyclers
Mixed Bipolar Disorder
• Often unrecognized although also
controversial regarding epidemic status
• Often misdiagnosed
• Often untreated
• Often inadequately treated
Suicide Risk Factors
• 22% of adolescents with completed suicides
had bipolar disorder
• Family history of suicide
• Substance abuse i.e. adolescent with
impulse control disorder, depression,
suicidality, substance use and access to a
weapon is potential for lethality
History of Prior Attempts
• Males who have made prior attempts are
more predictive of completing suicide than
females
• Only with half of all suicide completers is it
verified that they made prior suicide
attempts before their death
• Repeating an episode within one year of the
first attempt range from 14%-26%.
• A much debated risk factor of suicidality is
whether an adolescent is gay or lesbian.
• Russel and Joyner study
– Nationally representative data
– Are youths who report same-sex sexual
orientation at greater risk for suicidal thoughts
and suicide attempts than their peers?
– Are these youth still at greater risk than their
peers after critical adolescent suicide risk
factors are taken into account?
• Youth with same-sex orientation
are two times more likely than
their same sex peers to attempt
suicide but depression and alcohol
use are precursors to suicidality.
• 85% of same-sex orientation
teenagers have not considered
suicide at all (72% of females 85%
of males)
Impact of Cultural Factors
• Suicide risk of African
Americans rose dramatically
after 1986 but since then rates
have declined.
• Heritage/Cultural Factors
• Internalization of racist
stereotypes that may have
led to the rise in self
destructive behavior
• High rates of homicide
and substance abuse
among blacks; self
destructive behavior
• Expressions of rage are
turned inward or outward
• Skepticism/fearful of the
medical establishment
• “From the cradle to the
pulpit to the grave, many
blacks are taught that
suffering on earth leads to
great rewards in the
afterlife.”
Epidemiology of Bipolar Disorder
• Prevalence: 1% of population Adults =
Adolescents
• Males = Females
• 2-3 million American adults are diagnosed
with bipolar disorder
• NIMH estimates that one in very one
hundred people will develop the disorder
Controversy
•
•
•
•
Severity and duration
Onset before puberty is estimated to be rare
Peak between 15-19 years old
Retrospective study of adults
Assessment/Diagnosis of Bipolar
Disorder
• Often very complicated; it mimics many
other disorders and has comorbidity
(presents with other disorders)
• Alphabet soup diagnosis
• Half of bipolar children have relatives with
bipolar disorder
• Atypical presentation in juvenilesexacerbation of disruptive behavior,
moodiness, low frustration tolerance,
explosive anger and difficulty sleeping at
night
• ADHD confusion although identifying
presence of mood disorder helpful in
guiding treatment
• Comorbidity of ADHD/BPD more severe
presentation, often severe affect
dysregulation, marked impairment, violent
temper outbursts
DIGFAST – Mental Status Exam
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Distractible
Insomnia
Grandiosity/Super-hero mentality
Flight of ideas
Activities that are dangerous or hypersexual
Speech is rapid
Thought insertion
• Major depression often presents first
(estimated that 20 - 40% of children
presenting with major depression within 5
years will be bipolar)
• Comorbidity
• 70 - 90 % of adolescents have other
disorders
• ADHD, Conduct Disorder, Substance abuse
Medications
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•
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Mood Stabilizers
Lithium
Divalproex Sodium (Depakote)
Carbamezapine
Newer Agents
•
•
•
•
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Neurontin
Lamictal
Topamax
Gabatril
Atypical antipsychotics
Key Point
• Just because a child improves on a mood
stabilizer does not prove the diagnosis.
Mood stabilizers have been used for a long
time to help with aggression in children
Multiple Modalities
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Psychotherapy
Psychoeducation/Support
School Support/Consultation
Residential Placement, Acute Hospitalization
-Mood Charting
-Teach Good Sleep Hygiene
Legal intervention
Hope
Post Traumatic Stress Disorder
• Hyperarousal (most common symptom;
startled response, behavioral irritability,
sleep disturbances, regulatory functions off,
hypervigilance, emotional numbing, or
dissociation)
• Nightmares
• Flashbacks
• Upsetting reminders and triggers
Active Avoidance
Passive Avoidance
• Fight or Flight response alarm
reaction then fear (experience in
the high school, sometimes
inappropriate escalating
behavior by adults to child’s
apparent impertinence)
Trauma: Common Ways of Thinking
•
•
•
•
•
•
“All or nothing”
“Again and Again”
“Must”, “Should”, or “Never”
“End of the world”
Always blaming yourself
Thinking on the downside
• Secondary attachment figure
• Ross Greene material
PTSD
• No particular medication
• Low doses of SSRI if depression and
anxiety present
• Risks/benefits
Obsessive-Compulsive Disorder
• Persistent ideas or impulses
• Purposeful repetitive behaviors,
compulsions
• Behavioral treatment, cognitive therapy
with symptom immersion very useful
• SSRIs are useful, sometimes in relatively
high doses
Wait, by Galway Kinnell
Wait, for now.
Distrust everything, if you have to.
But trust the hours.
Haven't they
carried you everywhere, up to now?
Personal events will become interesting again.
Hair will become interesting.
Pain will become interesting.
Buds that open out of season will become lovely again.
Second-hand gloves will become lovely again,
their memories are what give them the need for other hands. And the
desolation of lovers is the same: that enormous emptiness
carved out of such tiny beings as we are
asks to be filled; the need
for the new love is faithfulness to the old.
Wait.
Don't go too early.
You're tired. But everyone's tired.
But no one is tired enough.
Only wait a while and listen.
Music of hair,
Music of pain,
music of looms weaving all our loves again.
Be there to hear it, it will be the only time,
most of all to hear,
the flute of your whole existence,
rehearsed by the sorrows, play itself into total exhaustion
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All You Wanted to Know About Medications But Were …